Brown

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Browns Syndrome

• Dr Sunayana Bhat
• Consultant
• Paediatric ophthalmology , Strabismus and Neuro
  ophthalmology
• Vasan eye care , Mangalore
• Ph 9611102754
• chanyn9_at_gmail.com

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Historical Background

• 1950 Harold W. Brown
• Published on an unusual motility disorder,
  characterized limited elevation in adduction
• 1970s Short anterior sheath of the superior
  oblique tendon
• mid 1970s A tight or short superior oblique
  tendon

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Pathophysiology

• Brown syndrome can be divided into
• Congenital
• Acquired.

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• To understand Browns syndrome
• understand relationships.
• Particularly the relationship between the
  superior and inferior oblique.

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Normal superior and inferior oblique relationship
in adduction
Dr. G.Vicente
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Brown syndrome OS
Divergence in upgaze
Down shoot in attempted elevation in adduction?
Dr. G.Vicente
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Brown Syndrome OS (from above)
Dr. G.Vicente
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Congenital

• Wright hypothesis

• Computer model
• computer simulation of Brown syndrome, using
  two specific models
• a short superior oblique tendon
• a stiff superior oblique tendon (stretched
  sensitivity).
• Stiff muscle tendon complex
• ( type of CFEOM ?????)

• Helveston theory

• Elongation - telescoping mechanism
• Central tendon fibres
• ( anomalous ?????)

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Aquired Brown s Syndrome
Peritrochlear scarring and adhesions Chronic sinusitis, trauma , blepharoplasty and fat removal, and lichen sclerosus et atrophicus and morphea
Tendon-trochlear inflammation and edema - Idiopathic inflammatory (pain and click), trochleitis with superior oblique myositis, acute sinusitis, adult rheumatoid arthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, possibly distant trauma (cardiopulmonary resuscitation CPR and long bone fractures), and possibly postpartum hormonal changes
Superior nasal orbital mass - Glaucoma implant and neoplasm
Tight or inelastic superior oblique muscle - Thyroid disease (inelastic muscle), peribulbar anesthesia (inelastic tendon), Hurler-Scheie syndrome (inelastic tendon), and superior oblique tuck (short tendon)
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Acquired browns
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Some statistics

• 1 in 450 strabismic pts ..
• 35 have a squinting relative
• Laterality , sex predilection in conclusive

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History

• Diplopia
• Rare suppression.
• Pain
• Acquired Brown syndrome present with inflammatory
  signs.
• - supranasal orbital pain
• - tenderness
• - intermittent limitation of elevation in
  adduction

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Hallmark Features

• Elevation limitation in adduction
• Divergence in upgaze
• FDT VE
• Other
• Downshoot in adduction
• Widening of palpebral fissure on adduction
• Ortho or hypo in primary position
• Head posture ( chin up )
• Audible Click

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Pseudo Brown

• Congenital

• Acquired

• Anomalous inferior orbital adhesions
• Posterior orbital bands

• Floor fracture
• Retinal band around inferior oblique muscle
• Inferior temporal adhesions

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Differential Diagnosis

• Inferior oblique paralysis
• DEP
• Fracture orbital floor
• CFEOM
• Graves disease

• Hypo in primary gt15 PD
• SO Overaction
• Ductionsgt versions

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Brown Syndrome Treatment

• Treat the underlying condition.
• Surgery indications
• Hypotropia in primary
• Anomalous head posture severe chin up.

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Brown Syndrome Tx SO tenotomy(for the less shy)
SR
SR
MR
LR
LR
RM
IR
IR
IO
IO
Dr. G.Vicente
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For those surgeons who are a little too
chicken to completely cut the SO tendon and cause
a SO palsyChicken suture technique
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Brown Syndrome Tx Chicken suture
Dr. G.Vicente
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Or else. Try the synthetic chicken trick
silicone expander
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Silicone expander
Dr. G.Vicente
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Thank you !